Cerebrospinal Fluid Removal Research Articles

Pharmacology of PIEZO1 channels.

PIEZO1 is a eukaryotic membrane protein that assembles as trimers to form calcium-permeable, non-selective cation channels with exquisite capabilities for mechanical force sensing and transduction of force into effect in diverse cell types that include blood cells, endothelial cells, epithelial cells, fibroblasts and stem cells and diverse systems that include bone, lymphatics and muscle. The channel has wide-ranging roles and is considered as a target for novel therapeutics in ailments spanning cancers and cardiovascular, dental, gastrointestinal, hepatobiliary, infectious, musculoskeletal, nervous system, ocular, pregnancy, renal, respiratory and urological disorders. The identification of PIEZO1 modulators is in its infancy but useful experimental tools emerged for activating, and to a lesser extent inhibiting, the channels. Elementary structure-activity relationships are known for the Yoda series of small molecule agonists, which show the potential for diverse physicochemical and pharmacological properties. Intriguing effects of Yoda1 include the stimulated removal of excess cerebrospinal fluid. Despite PIEZO1's broad expression, opportunities are suggested for selective positive or negative modulation without intolerable adverse effects. Here we provide a focused, non-systematic, narrative review of progress with this pharmacology and discuss potential future directions for research in the area.

A Comparison of Denoising Approaches for Spoken Word Production Related Artefacts in Continuous Multiband fMRI Data

Abstract It is well-established from fMRI experiments employing gradient echo echo-planar imaging (EPI) sequences that overt speech production introduces signal artefacts compromising accurate detection of task-related responses. Both design and post-processing (denoising) techniques have been proposed and implemented over the years to mitigate the various noise sources. Recently, fMRI studies of speech production have begun to adopt multiband EPI sequences that offer better signal-to-noise ratio (SNR) and temporal resolution allowing adequate sampling of physiological noise sources (e.g., respiration, cardiovascular effects) and reduced scanner acoustic noise. However, these new sequences may also introduce additional noise sources. In this study, we demonstrate the impact of applying several noise-estimation and removal approaches to continuous multiband fMRI data acquired during a naming-to-definition task, including rigid body motion regression and outlier censoring, principal component analysis for removal of cerebrospinal fluid (CSF)/edge-related noise components, and global fMRI signal regression (using two different approaches) compared to a baseline of realignment and unwarping alone. Our results show the strongest and most spatially extensive sources of physiological noise are the global signal fluctuations arising from respiration and muscle action and CSF/edge-related noise components, with residual rigid body motion contributing relatively little variance. Interestingly, denoising approaches tended to reduce and enhance task-related BOLD signal increases and decreases, respectively. Global signal regression using a voxel-wise linear model of the global signal estimated from unmasked data resulted in dramatic improvements in temporal SNR. Overall, these findings show the benefits of combining continuous multiband EPI sequences and denoising approaches to investigate the neurobiology of speech production.

Predicting Gait Speed Improvement in Idiopathic Normal Pressure Hydrocephalus Patients: The Role of Evans Index and Ventricular Volume.

Objective This study aims to investigate the association between specific imaging parameters, namely, the Evans index (EI) and ventricular volume (VV), and the variation in gait speed observed in patients with idiopathic normal pressure hydrocephalus (iNPH) before and after cerebrospinal fluid (CSF)removal/lumbar drain (LD). Furthermore, it seeks to identify which imaging parameters are the most reliable predictors for significant improvements in gait speed post procedure. Methods In this retrospective analysis, the study measured the gait speed of 35 patients diagnosed with idiopathic normal pressure hydrocephalus (iNPH) before and after they underwent CSF removal. Before lumbar drain (LD), brain images were segmented to calculate the Evans index and ventricular volume. The study explored the relationship between these imaging parameters (the Evans index and ventricular volume) and the improvement in gait speed following CSF removal. Patients were divided into two categories based on the degree of improvement in gait speed, and we compared the imaging parameters between these groups. Receiver operating characteristic (ROC) curve analysis was employed to determine the optimal imaging parameter thresholds predictive of gait speed enhancement. Finally, the study assessed the predictive accuracy of these thresholds for identifying patients likely to experience improved gait speed post-LD. Results Following CSF removal/lumbar drain, the participants significantly improved in gait speed, as indicated by a paired sample t-test (p-value = 0.0017). A moderate positive correlation was observed between the imaging parameters (EI and VV) and the improvement in gait speed post-LD. Significant differences were detected between the two patient groups regarding EI, VV, and a composite score (statistical test value = 3.1, 2.8, and 2.9, respectively; p-value < 0.01). Receiver operating characteristic (ROC) curve analysis identified the optimal thresholds for the EI and VV to be 0.39 and 110.78 cm³, respectively. The classification based on these thresholds yielded significant associations between patients displaying favorable imaging parameters and those demonstrating improved gait speed post-LD, with chi-square (χ²) values of 8.5 and 7.1, respectively, and p-values < 0.01. Furthermore, these imaging parameter thresholds had a 74% accuracy rate in predicting patients who would improve post-LD. Conclusion The study demonstrates that ventricle volume and the Evans index can significantly predict gait speed improvement after lumbar drain (LD) in patients with iNPH.

Correlating Evans Index, Callosal Angle, and Lateral Ventricle Volume With Gait Response Outcomes in Idiopathic Normal Pressure Hydrocephalus Diagnosis.

Radiological imaging is pivotal in diagnosing idiopathic normal pressure hydrocephalus (iNPH), given the similarity of its symptoms to other neurodegenerative diseases. We aimed to correlate the Evans index (EI), callosal angle (CA), and the volume of the lateral ventricles measured before cerebrospinal fluid removal with the resultant outcomes in gait response. In our retrospective study, we identified 42 patients with a diagnosis of iNPH. These patients underwent gait analysis, imaging, and lumbar puncture. Radiological assessments included measurements of CA EI and lateral ventricular volume. Clinically, we assessed the following 4 gait parameters: cadence, gait speed, stride length, and timed up and go. Change in the 4 gait parameters was calculated, normalized, and compiled into a composite score, following which the group was divided into 'responders' and 'nonresponders' based on z score of 0.5. Our dependent variable was clinical improvement in gait, and our independent variables included lateral ventricular volume, EI, and CA. We performed a Wilcoxon rank-sum test to compare significant responder status using CA, EI, and lateral ventricle volume. A receiver operating characteristic analysis was employed to determine which volume measurement exhibited the strongest correlation with responder status. Determining the significant variables, a chi-square analysis was subsequently conducted.A significance threshold was set at P < 0.05. All our statistical evaluations were conducted in the Spyder environment, which is compatible with Python 3.10. There was a significant difference for responder status in EI and lateral ventricle volume. Evan index showing a statistic of 2.202 ( P value = 0.02) and lateral ventricle volume demonstrating a statistic of 2.086 ( P value = 0.03). Subsequent exploration using receiver operating characteristic analysis, with area under the curve of 0.71, identified 105.40 cm 3 as the most robustly correlated volume threshold with responder status. The lateral ventricular volume demonstrates a stronger correlation with gait improvement compared to the CA or EI. These observations indicate that evaluating the lateral ventricle volume before lumbar puncture could serve as a predictor for gait response after lumbar puncture in individuals with normal pressure hydrocephalus.

Effect of Parenchymal Arachnoid on Brain Fluid Transport.

The pia-arachnoid is a critical component of cerebrospinal fluid removal. It covers and invaginates into the brain parenchyma, and physiologic failure results in hydrocephalus and cerebral edema. The purpose of this study was to characterize the role of arachnoid within brain parenchyma and determine if water flux and solute transport are affected by these intra-parenchymal cells. An immortalized arachnoid rat cell line was used to seed 300-μm organotypic rat brain slices of 4-week-old rats. Fluid and tracer transport analyses were conducted following a 7-10 day intraparenchymal growth period. The development of an arachnoid brain slice model was characterized using diffusion chamber experiments to calculate permeability, diffusion coefficient, and flux. Labeled rat arachnoid cells readily penetrated organotypic cultures for up to 10 days. A significant reduction of dye and water flux across arachnoid-impregnated brain slices was observed after 3 hours in the diffusion chamber. Permeability decreased in whole brain slices containing arachnoid cells compared to slices without arachnoid cells. In comparison, a significant reduction of dextran across all slices occurred when molecular weights increased from 40 to 70 kDa. Tracer and small molecule studies show that arachnoid cells' presence significantly impacts water's movement through brain parenchyma. Size differential experiments indicate that the permeability of solute changed substantially between 40 and 70 kDa, an essential marker of blood-CSF barrier definition. We have developed an arachnoid organotypic model that reveals their ability to alter permeability and transport.

428 The Lumbar Tap Trial Experience: An Analysis of Outcomes in 133 Adult Normal Pressure Hydrocephalus Patients Undergoing 2-Day Lumbar Tap Trial at a Single Center

INTRODUCTION: Lumbar Tap Trial (LTT) with high volume cerebrospinal fluid (CSF) removal is one of the primary adjunct testing modalities at a neurosurgeon’s disposal in the diagnosis of normal pressure hydrocephalus (NPH). Patients responsive to LTT may receive permanent fluid diversion by way of shunt placement. METHODS: Retrospective review of the electronic medical records of 133 patients that underwent a 2-day LTT by a single surgeon at our adult hydrocephalus center was conducted. Each patient has been closely followed at our hydrocephalus clinic from the time of symptomatic presentation through LTT, eventual shunt placement (if performed), and frequent post-operative assessments. Assessment of improvement during LTT and following shunt placement includes a timed 25 ft. walk test at our clinic. RESULTS: From 2016 – present, 133 patients have undergone 136 completed LTTs. During initial LTT, no major complications such as death, infection, hemorrhage, or nerve-root injury were seen. Minor complications included post-tap low back pain, headache, and transient nerve-root irritation. Average improvement during timed 25 ft. walk test was 6.6 sec following LTT. Average improvement in timed walk test in patients receiving shunt placement was 13.9 sec compared to post LTT walk time. CONCLUSION: In patients with suspected NPH, high-volume LTT was found to be an effective and safe diagnostic tool in our patient population. Patients demonstrating significant objective improvement during a timed walk test are frequently recommended for shunting. Patients undergoing shunt placement following improvement on LTT continued to improve with a mean decrease in walk time post-operatively, highlighting the effectiveness of LTT in predicting symptomatic response to shunt placement.

Amyloid Positive Hydrocephalus: A Hydrocephalic Variant of Alzheimer's Disease?

Alzheimer's disease (AD) and normal pressure hydrocephalus (NPH) commonly coexist. We aimed to characterize an overlapping syndrome of AD and NPH that presents with gait disturbance, ventriculomegaly on magnetic resonance imaging, and significant amyloid deposition on positron emission tomography (PET). Of 114 patients who underwent cerebrospinal fluid (CSF) drainage for a possible diagnosis of NPH between 2015 and 2020 in Samsung Medical Center, we identified 24 patients (21.1%) with the NPH patients with amyloid deposition on PET, which we referred to as hydrocephalic AD in this study. We compared their clinical and imaging findings with those of 123 typical AD without hydrocephalic signs/symptoms. We also investigated the frequency and potential predictors of the tap test response in hydrocephalic AD. Evans' index was 0.36±0.03, and a disproportionately enlarged subarachnoid space was present in 54.2% of the hydrocephalic AD patients. The mean age (75.2±7.3 years) and the APOE4 frequency (68.2%) did not differ from those of AD controls. However, the hydrocephalic AD patients showed better memory and language performance, and a thinner cingulate cortex. About 42% of the hydrocephalic AD patients responded to the tap test, of whom seven underwent shunt surgery. Cognition did not improve, whereas gait improved after shunt surgery in all. Hydrocephalic AD has different neuropsychological and imaging characteristics from typical AD. Future studies are warranted to further investigate the effect of CSF removal on their clinical course and to elucidate the pathophysiological interaction between amyloid and NPH.

Intraparenchymal hemorrhage after serial ventricular reservoir taps in neonates with hydrocephalus and association with neurodevelopmental outcome at 2 years of age.

Decompressing the ventricles with a temporary device is often the initial neurosurgical intervention for preterm infants with hydrocephalus. The authors observed a subgroup of infants who developed intraparenchymal hemorrhage (IPH) after serial ventricular reservoir taps and sought to describe the characteristics of IPH and its association with neurodevelopmental outcome. In this multicenter, case-control study, for each neonate with periventricular and/or subcortical IPH, a gestational age-matched control with reservoir who did not develop IPH was selected. Digital cranial ultrasound (cUS) scans and term-equivalent age (TEA)-MRI (TEA-MRI) studies were assessed. Ventricular measurements were recorded prior to and 3 days and 7 days after reservoir insertion. Changes in ventricular volumes were calculated. Neurodevelopmental outcome was assessed at 2 years corrected age using standardized tests. Eighteen infants with IPH (mean gestational age 30.0 ± 4.3 weeks) and 18 matched controls were included. Reduction of the ventricular volumes relative to occipitofrontal head circumference after 7 days of reservoir taps was greater in infants with IPH (mean difference -0.19 [95% CI -0.37 to -0.004], p = 0.04). Cognitive and motor Z-scores were similar in infants with and those without IPH (mean difference 0.42 [95% CI -0.17 to 1.01] and 0.58 [95% CI -0.03 to 1.2]; p = 0.2 and 0.06, respectively). Multifocal IPH was negatively associated with cognitive score (coefficient -0.51 [95% CI -0.88 to -0.14], p = 0.009) and ventriculoperitoneal shunt with motor score (coefficient -0.50 [95% CI -1.6 to -0.14], p = 0.02) after adjusting for age at the time of assessment. This study reports for the first time that IPH can occur after a rapid reduction of the ventricular volume during the 1st week after the initiation of serial reservoir taps in neonates with hydrocephalus. Further studies on the use of cUS to guide the amount of cerebrospinal fluid removal are warranted.

Optical Coherence Tomography to Monitor Rebound Intracranial Hypertension with Increased Papilledema after Lumbar Puncture

Objective: We report that lumbar puncture (LP) with removal of cerebrospinal fluid (CSF) induced rebound intracranial hypertension with increased papilledema as monitored by optical coherence tomography (OCT). Background: Severe papilledema causes visual field loss and central vision damage if untreated. Fundoscopy is a key to diagnose papilledema, but is not sensitive enough to monitor therapeutic effects. Methods: OCT was applied to follow a 24-year-old woman with headache, visual dysfunction, severe bilateral papilledema, and elevated CSF opening pressure. She was first treated with serial LP, which led to symptom deterioration, increased CSF pressure, and increased the retinal nerve fiber layer (RNFL) thickness. She was then successfully treated with acetazolamide and furosemide. Results: OCT showed reduction of RNFL thickness directly after LP with CSF removal, accompanied with reduced CSF pressure. Increased RNFL thickness accompanied with worsened headache, visual dysfunction, and increased CSF pressure was observed on the next day after LP. Less than 24 h after start of medication, the symptoms had reversed and RNFL thickness was reduced. The patient was symptom-free 2 weeks after starting on medical treatment. Papilledema had vanished on fundoscopy 6 weeks after the therapy, and RNFL thickness was normalized at 3 months of follow-up. Conclusion: This case provides evidence that OCT is an objective and sensitive tool to monitor papilledema and its response to therapy, and thereby important to help in correct clinical decision-making.

Role of Lumbar Puncture In Traumatic Brain Injury

Background: Cerebrospinal fluid (CSF) drainage via ventricular puncture is an established therapy ofelevated intracranial pressure (ICP). In contrast, lumbar CSF removal is believed to be contraindicated withintracranial hypertension.Method: We investigated the safety and efficacy of lumbar CSF drainage to decrease refractory elevatedICP in a small cohort of patients with traumatic brain injury (TBI). A score (0–8 points) was used to assesscomputed tomography (CT) images for signs of herniation and for patency of the basal cisterns. All patientsreceived lumbar CSF drainage either as a continuous drainage or as a single lumbar puncture (LP). Type andmethod of CSF drainage, mean ICP 24 h prior and after CSF removal, and adverse events were documented.Outcome was assessed after 3 months (with dichotomized Glasgow outcome scale).Results: Eight patients were evaluated retrospectively. n = 5 suffered a moderate, n = 2 a severe TBI (oneGlasgow coma score not documented). The CT score was ?5 in all patients prior to LP and decreased afterpuncture without clinical consequences in two patients. The amount of CSF removal did not correlate withscore changes (P = 0.45). CSF drainage led to a significant reduction of mean ICP (from 22.3 to 13.9 mmHg,P = 0.002). Continuous drainage was more effective than a single LP. Three of eight patients reached afavorable outcome.Conclusions: Lumbar CSF removal for the treatment of intracranial hypertension is effective and safe,provided the basal cisterns are discernible, equivalent to ?5 points in the proposed new score. The scoreneeds further validation.

Optical Coherence Tomography Revealing Ganglion Cell Loss in Idiopathic Normal Pressure Hydrocephalus

Although there may theoretically be a disturbance in the eye or the visual pathways due to abnormal cerebrospinal fluid (CSF) dynamics in idiopathic normal pressure hydrocephalus (iNPH), it has not been studied systemically. Optical coherence tomography (OCT) is a noninvasive, reproducible procedure for quantitative and qualitative analysis of retinal morphology. OCT was used to study the eye fundus before and after a CSF tap test in patients with iNPH compared with healthy individuals (HIs). Twelve patients with iNPH (6 females and 6 males) with a median age of 76 years (64-84 years) and 21 HIs (11 females and 10 males) with a median age of 73 years (64-79 years) were included. The patients underwent neurological, cognitive, and physiotherapeutic evaluation. Brain magnetic resonance imaging, CSF tap test via lumbar puncture, and subsequently CSF analysis were performed. OCT was performed before and after CSF removal. HIs underwent OCT once. The patients had significantly reduced retinal ganglion cell layer thickness 71 μm (56-81 μm) compared with the HIs, 79.5 μm (72-90 μm) (P = 0.001), but no significant changes were observed before or after the CSF tap test. All patients improved in motor function in a 10-m walk test after the CSF tap test. The median CSF pressure was 15 and 1 cm H2O, respectively, before and after lumbar puncture with removal of median 43.5 mL CSF. This pilot study shows OCT findings that differ from HIs and implies a rational for becoming a valuable tool in the diagnosis of iNPH. Further studies are warranted to elucidate the pathology of the retina in iNPH.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Prevalence and Trends in Management of Idiopathic Normal Pressure Hydrocephalus in the United States: Insights from the National Inpatient Sample

Over the past 2 decades, management of idiopathic normal pressure hydrocephalus (iNPH) has evolved significantly. In the current study, we sought to evaluate the national prevalence and management trends of iNPH in the United States using a national database. The National Inpatient Sample was queried for patients with an International Classification of Diseases diagnosis code for iNPH from 2007 to 2017. Trends in prevalence and procedure type were evaluated per 100,000 discharges and as a percentage of discharges, using weighted discharges. Utilization of procedure type across U.S. regions and hospital types was also compared. From 2007 to 2017, 302,460 weighted discharges with any diagnosis code for iNPH, aged ≥60 years, were identified. Prevalence ranged from 0.04% to 0.20% (41/100,000 to 202/100,000) among admitted patients ≥60 years old, giving an average prevalence during the study duration of 0.18% (179/100,000). Of 66,759 weighted discharges with a primary diagnosis code of iNPH undergoing surgical management, ventriculoperitoneal shunt (72.0% of discharges, n= 48,977) was most commonly used; of these, 9.3% (n= 4567) were performed laparoscopically. This result was followed by lumbar peritoneal shunt (15.1% of discharges, n= 10,441). Up to 15.1% (n= 9990) of discharges reported only a lumbar puncture, assumed to be only diagnostic, for screening, or part of serial cerebrospinal fluid removal procedures. Significant discrepancies in procedure utilization were also identified among hospitals in the Western, Southern, Northeast and Midwest regions, as well as between urban and rural hospitals (P < 0.05). We have summarized the national prevalence of iNPH, trends in its management over the previous decade and trends by region and hospital type.

Endoscopic Excision of Intraventricular Neurocysticercosis Cyst with an Angiocatheter: A Retrospective Analysis.

Introduction:An intraventricular cysticercus cyst is observed in 7%–30% patients of neurocysticercosis (NCC). Apart from causing arachnoiditis, intraventricular NCC (IVNCC) can cause sudden death due to acute episodes of hydrocephalus. Various treatment modalities available are external cerebrospinal fluid (CSF) diversion, microsurgical removal, and endoscopic management. There is no consensus regarding the optimal surgical treatment strategy. We are presenting our experience by doing a retrospective analysis of 26 patients having endoscopic removal of IVNCC with a rigid endoscope and angiocatheter.Aim:The aim of this study is to evaluate the results of neuroendoscopy in restoring the CSF pathway and removal of the cyst in patients of IVNCC.Materials and Methods:Retrospective analysis of clinical record and follow-up of 26 patients of IVNCC who were treated endoscopically between 2010 and 2018 was done. The diagnosis of IVNCC was made based on contrast enhanced magnetic resonance imaging of the brain. Transcranial endoscopy with 0° endoscope was performed through the frontal burr hole. Third ventriculostomy and removal of the cysticercus cyst with angiocatheter were the procedures done.Results:The success rate of intraventricular cyst excision, whether complete or partial, was 100% (14/14) in the third ventricular cyst, 62.5% (5/8) in the fourth ventricular cyst and 100% (4/4) in the lateral ventricular cyst. The overall success rate of cyst excision by endoscopy was 88.46%. The overall successful CSF flow pathway was established in 88.46% cases. The mean duration of follow-up was 44 months, and all the patients were found symptom free in the follow-up period.Conclusion:Neuroendoscopy, being a single burr hole technique successfully providing internal CSF diversion and cyst removal, is the treatment modality of choice for IVNCC.

The Utility of Serial Cerebrospinal Fluid Removal in Elderly Patients with Idiopathic Normal-Pressure Hydrocephalus?

The Utility of Serial Cerebrospinal Fluid Removal in Elderly Patients with Idiopathic Normal-Pressure Hydrocephalus?

Assessing the Impact of 3% Hypertonic Saline Hyperosmolar Therapy on Intubated Children With Isolated Traumatic Brain Injury by Cerebral Oximetry in a Pediatric Emergency Setting.

BACKGROUND Intubated pediatric patients with isolated traumatic brain injury (TBI) are a diagnostic challenge for early detection of altered cerebral physiology instigated by trauma-induced increased intracranial pressure (ICP) while preventing secondary neuronal damage (secondary insult detection) and assessing the effects of increased ICP therapeutic interventions (3% hypertonic saline [HTS]). Invasive brain tissue oxygen monitoring is guiding new intensive care unit TBI management but is not pediatric emergency department (PED) readily accessible. Objective measurements on pediatric isolated TBI-altered bihemispheric cerebral physiology and treatment effects of 3% HTS are currently lacking. Cerebral oximetry can assess increased ICP-induced abnormal bihemispheric cerebral physiology by measuring regional tissue oxygenation (rcSO2) and cerebral blood volume index (CBVI) and the mechanical cerebrospinal fluid removal effects on the increased ICP-induced abnormal bihemispheric cerebral physiology.In the PED intubated patients with isolated TBI, assessing the 3% HTS therapeutic response is solely by vital signs and limited clinical assessment skills. Objective measurements of the 3% HTS hyperosmolar effects on the PED isolated TBI patients' altered bihemispheric cerebral physiology are lacking. We believe that bihemispheric rcSO2 and CBVI could elucidate similar data on 3% HTS impact and influence in the intubated isolated TBI patients. OBJECTIVE This study aimed to analyze the effects of 3% HTS on bihemispheric rcSO2 and CBVI in intubated patients with isolated TBI. METHODS An observational, retrospective analysis of bihemispheric rcSO2 and CBVI readings in intubated pediatric patients with isolated TBI receiving 3% HTS infusions, was performed. RESULTS From 2010 to 2017, 207 intubated patients with isolated TBI received 3% HTS infusions (median age, 2.9 [1.1-6.9 years]; preintubation Glasgow Coma Scale score, 7 [6-8]). The results were as follows: initial pre-3% HTS, 43% (39.5% to 47.5%; left) and 38% (35% to 42%; right) for rcSO2 80%, and 16.5 (6 to 33, P 80%, and 16.5 (6 to 33, P 10 showed rcSO2 10 and required the greatest number of 3% HTS infusions. For 3% HTS 15% rcSO2 change time effect, all patients achieved positive change with subdural hematomas and hemispheric rcSO2 readings 10 demonstrated the greatest significant positive delta change and required the greatest numbers of 3% HTS infusions. Overall, 3% HTS produced a significant positive 15% change within 2.1 minutes of infusion, whereas heart rate showed no significant change. During trauma neuroresuscitation, especially in intubated isolated TBI patients requiring 3% HTS, cerebral oximetry has shown its functionality as a rapid adjunct neurological, therapeutic assessment tool and should be considered in the initial emergency department pediatric trauma neurological assessment and neuroresuscitation regimen.

The benefit of delayed reassessment post high-volume CSF removal in the diagnosis of shunt-responsive idiopathic normal-pressure hydrocephalus

The principle aim of the study was to demonstrate the value of performing delayed reassessment in the diagnosis of idiopathic normal-pressure hydrocephalus (iNPH) and selection of suitable candidates for ventriculoperitoneal shunting (VPS).Thirty-one consecutive patients underwent the NPH protocol at the Flinders Medical Centre between March 2017 and November 2018. The protocol involved mobility and cognitive testing with reassessment post high-volume cerebrospinal fluid (CSF) removal at 24 h and 48 h. The Assessment of Quality of Life 6D (AQoL-6D) questionnaire and International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form (ICIQ-UI SF) were completed and repeated again at 6 weeks and 6 months post shunting. Results were analysed to determine the significance of delayed reassessment.Twenty patients (64.5%) underwent insertion of a VPS on the basis of objective improvements and specific criteria. Of these, 6 patients (30%) were shunted based on delayed reassessment at 48 h post CSF removal. Continued improvements were seen for all mobility and cognitive tests from baseline to 48 h post CSF removal. At 6 weeks and 6 months post shunting, there was an overall mean improvement in AQoL-6D and ICIQ-UI SF for the cohort and the improvement was also observed in the subgroup of patients who met shunt criteria at 48 h post CSF removal.In the diagnosis of shunt-responsive idiopathic normal-pressure hydrocephalus, delayed reassessment post CSF removal improves sensitivity and is therefore important.

The Outcomes Of Serial Cerebrospinal Fluid Removal In Elderly Patients With Idiopathic Normal Pressure Hydrocephalus.

PurposeElderly patients with iNPH (idiopathic normal pressure hydrocephalus) might be potentially high-risk surgical patients. Our purpose was to investigate the outcome of serial removal of cerebrospinal fluid (CSF) in the patients with iNPH who refused to have the ventriculoperitoneal or lumboperitoneal shunt surgery or had contraindications to them.Patients and methodsThere were 42 patients, with a median age of 78 years. Recurrent CSF removal was performed when the patients had deteriorated gait which was defined as >10% pre-removal change on the average of two walking trials during timed up and go (TUG). All the patients underwent mini-mental status examination (MMSE), frontal assessment battery (FAB), Stroop test, Tinetti Performance Oriented Mobility Assessment (POMA), TUG and nine-hole peg test (NHPT) with the dominant hand, before and after CSF removal.ResultsThirty-five patients had two CSF removal procedures with a mean interim period of 7.4 months ranging from 1.5 to 35 months. Thirteen patients had three CSF removal procedures. The mean TUG scores were decreased after the first, second and third procedures (p<0.001; p<0.001; p=0.007; respectively). The POMA scores including both gait and balance components improved after the first and second procedures (p<0.05; for each). After the third procedure, the increase in POMA-balance score was statistically significant (p<0.05). After the first procedure, the FAB scores and NHPT scores were significantly improved (p<0.02). The median follow-up duration of the patients was 34.5 months.ConclusionThe deterioration of gait disturbance may be improved, and cognitive decline may be stabilized, at least postponed, by applying recurrent CSF removal in those unshunted patients with iNPH.

Impact of Neurapheresis System on Intrathecal Cerebrospinal Fluid Dynamics: A Computational Fluid Dynamics Study.

It has been hypothesized that early and rapid filtration of blood from cerebrospinal fluid (CSF) in postsubarachnoid hemorrhage patients may reduce hospital stay and related adverse events. In this study, we formulated a subject-specific computational fluid dynamics (CFD) model to parametrically investigate the impact of a novel dual-lumen catheter-based CSF filtration system, the Neurapheresis™ system (Minnetronix Neuro, Inc., St. Paul, MN), on intrathecal CSF dynamics. The operating principle of this system is to remove CSF from one location along the spine (aspiration port), externally filter the CSF routing the retentate to a waste bag, and return permeate (uncontaminated CSF) to another location along the spine (return port). The CFD model allowed parametric simulation of how the Neurapheresis system impacts intrathecal CSF velocities and steady-steady streaming under various Neurapheresis flow settings ranging from 0.5 to 2.0 ml/min and with a constant retentate removal rate of 0.2 ml/min simulation of the Neurapheresis system were compared to a lumbar drain simulation with a typical CSF removal rate setting of 0.2 ml/min. Results showed that the Neurapheresis system at a maximum flow of 2.0 ml/min increased average steady streaming CSF velocity 2× in comparison to lumbar drain (0.190 ± 0.133 versus 0.093 ± 0.107 mm/s, respectively). This affect was localized to the region within the Neurapheresis flow loop. The mean velocities introduced by the flow loop were relatively small in comparison to normal cardiac-induced CSF velocities.

Cerebrospinal Fluid Removal for Idiopathic Intracranial Hypertension: Less Cerebrospinal Fluid Is Best.

Although lumbar punctures (LPs) are used for diagnostic evaluation in idiopathic intracranial hypertension (IIH), they can also provide relief from IIH-associated headache. Conversely, low-pressure headache secondary to LP can be debilitating. Low-volume cerebrospinal fluid (CSF) removal to a "high-normal" closing pressure (CP), approximately 18-20 cm H2O, may result in relief of IIH-associated headache with a lowered frequency of post-LP headache. We conducted a single-center retrospective analysis from 2011 to 2016 of patients who underwent fluoroscopic LPs aiming for high-normal CPs. Inclusion criteria were as follows: 1) pre-existing diagnosis of IIH, or opening pressure (OP) and clinical findings diagnostic for IIH; 2) height and weight recorded within 1 year; 3) documented LP data parameters; and 4) one week post-LP follow-up documenting whether headache was worse, unchanged, or better. One hundred forty-six patients met the inclusion criteria. Mean age was 34.9 years ± 11.0, and mean body mass index was 39.2 kg/m ± 10.5. Mean volume removed was 9.7 mL ± 4.6. The mean CP was 17.9 cm H2O ±2.7. The mean pressure change (OP-CP) per volume removed was 1.50 cm H2O/mL ±0.6. Headache symptoms at follow-up were improved in 64% (80/125) of patients, worse in 26% (33/125), and unchanged in 10% (12/125). Eleven patients were headache-free, and 11 patients required hospital care for post-LP headache. Low-volume CSF removal to approximately 18 cm H2O resulted in relief of IIH-associated headache in most patients and a low incidence of post-LP headache. Although clinically variable, these data suggest that for every 1 mL of CSF removed, the CP decreases approximately 1.5 cm H2O.